Primary care access to radiology: Characteristics of trauma patients referred to the emergency department

Abstract Rationale, Aims and Objectives Low‐urgent Emergency Department (ED) attendances are a known contributing factor to ED crowding. In the Netherlands, general practitioners (GPs) have direct access to radiology facilities during office hours. Patients with radiographically confirmed traumatic injuries are subsequently referred to the ED. We analysed these ED trauma patients' characteristics, provided treatments and ED discharge diagnoses to identify the possibility of alternative care pathways. Methods Single‐centre retrospective observational study of trauma patients referred to the ED by the radiology department during office hours (January 2017–December 2017). Data were obtained from patient records. Descriptive statistics were used to analyse the extracted data. Results A total of 662 patients were included. The median age was 42 years (range: 1–100, interquartile range (IQR): 15–63) and patients presented to the ED with a median delay of 1 day (range: 0–112 days, IQR: 0–5). Most patients were referred for injuries involving the upper extremities (61.5%) and lower extremities (30%). A total of 48 additional diagnoses were made in the ED. The majority of injuries was classified as ‘minor’ (29.5%) or ‘moderate’ (68.3%) on the Abbreviated Injury Scale (AIS). The median length of stay in the ED was 65 min (range: 7–297 min, IQR: 43–102). Conclusion Most patients presented with low acuity injuries and often with a notable delay to the ED. This suggests that the majority of these patients do not necessarily need ED treatment, which may provide an opportunity to counter ED crowding.


| INTRODUCTION
Emergency Department (ED) crowding is a growing public health problem. It has been associated with a longer length of stay (LOS) in the ED, treatment delays, overutilization of diagnostic tools, higher hospital admission rates, poor patient outcomes and decreased patient satisfaction. [1][2][3] Several contributing factors have been identified, including increasing patient complexity, an ageing population, reduced hospital admission capacity and high rates of nonurgent visits and self-referring patients. 1 Improving patient flows and redirecting patients with nonurgent complaints to alternative health-care settings may help to reduce the workload of EDs.
In the Netherlands, the primary care system is welldeveloped and accessible 24 h a day. Musculoskeletal trauma is one of the main reasons to visit a general practitioner (GP). 4 During office hours, every GP has access to radiology services. In case of radiographic abnormalities detected by a radiologist, the patient is subsequently referred to the ED. The GP receives a radiology report with a notice of the ED referral. If an abnormality is ruled out, the GP remains responsible for evaluation and treatment. 5 In recent years, various GP cooperatives have also gained access to the hospital's radiology facilities, and several studies have examined the impact of this out-of-hours access. In line with expectations, those studies showed a decrease of minor traumatic injuries in the ED, suggesting a positive effect on ED crowding. 5,6 It seems likely that this also applies within office hours, but it has not been assessed yet. Furthermore, little is known on the delay between injury and diagnosis, and on the type of injuries these patients present with. Such information is essential to further improve the efficiency of this current healthcare trajectory.
The aim of this study was to analyse patient characteristics, provided treatments and discharge diagnoses of ED trauma patients referred by the radiology department during office hours. Furthermore, we collected information on additional diagnostics ordered in the ED with resultant extra diagnoses and treatments.

| METHODS
We performed a retrospective observational study of patients presenting to the ED of VieCuri Medical Center, a 500-bed teaching hospital with a Level 2 trauma centre in the southeast region of the Netherlands. The hospital serves a population of around 280,000 people and has an annual ED census of 25,000 patients. The ED is colocated with a GP cooperative for out-of-hours primary care. We  (blue, i.e., 'nonurgent' or green, i.e., 'standard'). The radiology order issued by the GP was considered incomplete in 73% of cases. Of the essential order elements, the timing of injury was most often missing (63%), followed by specific area of complaint (37%) and trauma mechanism (30%).

| DISCUSSION
In this study, patients referred to the ED with radiographically proven traumatic injuries following GP's access to radiology were analysed.
Injuries generally were of low acuity and patients presented with varying but considerable delays. Patients often received treatments of low complexity or instructions only and follow-up was not always indicated. This suggests that the majority of these patients do not necessarily need ED treatment, which may provide an opportunity to counter ED crowding and may help to provide the right care in the right place at the right time.
Although the causes of ED crowding are multifactorial and can be related to increased input (for example, high influx of patients), reduced throughput (for instance, bad logistics) and reduced output (for instance, reduced hospital bed capacity), several reports have shown that patients with nonurgent ED attendances are a contributing factor. 1,2,10-12 Furthermore, poor access to primary care is a critical driver of high ED volumes. 1,10 In the Netherlands, many EDs are colocated with GP cooperatives, forming so-called emergency care access points (ECAPs) after hours. Thijssen et al. [13][14][15] observed that these ECAPs were associated with a decrease in self-referred ED patients and an increase in hospital admission rates, suggesting an increased efficiency of ED utilization following ECAP implementa- tion. An additional advantage of co-location is the possibility of direct access to hospital diagnostics, such as radiology facilities. Previous Dutch studies assessed the effect of GPs' out-of-hours access to radiology facilities and found a substantial decrease in ED trauma patient referrals and increased patient satisfaction levels. 5,6,16 Consistent with those studies, the use of diagnostics by GPs in our study seemed adequate. Although 6.8% of patients received an extra ED diagnosis in addition to the radiology department referral indication, they were mainly classified as minor or moderate, and generally had no clinical consequences because of the delay to presentation or because no additional treatment was indicated.
It is well known that ED crowding is associated with delayed treatments, poor patient outcomes, decreased patient satisfaction, higher costs and a high burden for ED staff. Future studies should also assess which diagnoses not necessarily need hospital follow-up, but can be referred back to primary care.

| Strengths and weaknesses
A key limitation of this study is the study design, being a singlecentre observational study. We only studied the patients that were referred to the ED. Therefore, the occurrence of selection bias cannot be excluded in case radiographic abnormalities were either missed or regarded 'minor' by the radiologist with a subsequent referral back to the GP instead of the ED. Our study population only included patients who presented in the first 6 weeks of each quarter of the year, leading to an underestimation of patients in the ED with minor traumatic injuries on a yearly basis. It can therefore be assumed that adapting patient routing has a greater impact on relieving ED pressures than the study results imply. Furthermore, primary care access to radiology is not available in many countries.
The results of this study may therefore have limited generalizability.
Nonetheless, ED crowding is universal and this study provides novel insights into the flow of nonurgent trauma patients in the ED. It may help to improve existing care pathways in other emergency health care settings. Furthermore, it supports the common practice of redirecting nonurgent trauma patients to outpatient settings during the first wave of the COVID-19 pandemic.

| CONCLUSION
Primary care access to radiology aims to only refer patients with radiologically confirmed traumatic injuries to the ED and thereby reduce the number of trauma patient ED referrals. The patients in this cohort presented with a notable delay and injuries were mostly classified as low acuity. This suggests that not all of these patients necessarily need ED treatment, which may provide an opportunity to counter ED crowding by using alternative care pathways, such as outpatient clinics. The safety and feasibility of these pathways should be evaluated in future studies.